Ophthalmic Anaesthesia News - British Ophthalmic Anaesthesia

32 Pages·2005·1.03 MB·English

by  Chandra Kumar

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Ophthalmic Anaesthesia News
The Official Newsletter of the British Ophthalmic Anaesthesia Society
Issue 10, July 2004

Ophthalmic Anaesthesia News

The First World Congress Of Ophthalmic Anaesthesia
Page - Contents
1. The First World Congress Of London - April 2004
Ophthalmic Anaesthesia

6. Orbital exenteration under local
The very first world Congress of Ophthalmic Anaesthesia was hosted by
anaesthesia with intravenous
sedation BOAS at the Royal College of Physicians in London on the 15th and 16th of
9-11. Life Time Achievements April. The Congress was the “brainchild” of the secretary of BOAS, Professor
Awards Chandra Kumar, to coincide with the World Congress of Anaesthesia being
12. Observer variability in
held in Paris the following week. It was an adventurous undertaking for a
assessment of ophthalmic
relatively new Society, but with Chandra’s experience and enthusiasm, an
regional anaesthesia
14. Anaesthesia for botulinum attendance of nearly 200 delegates and faculty from over 40 countries, we were
toxin injections in ophthalmic confident that it would be successful.
surgery
18. News and information
The venue proved to be ideal, with excellent conference facilities and had the
21. BOAS membership
added advantage of a stroll in the adjacent Regent’s park during the Lunch
application form
23-25. OAS meeting details breaks! With the delightful spring sunshine I think our overseas delegates
27. Voluntary medical work gained a very favourable impression of London!
29. BOAS Membership list
32. Videoconference 2005
The congress opened on Thursday morning, with Professor Chris Dodds, the
meeting details
president of BOAS, chairing a session mainly devoted to training in

Ophthalmic Anaesthesia, with the views of both the colleges of Anaesthesia
and Ophthalmology being represented. Professor Roy Hamilton from Calgary
Editor:
also gave a global view of Ophthalmic Anaesthesia, and Tom Eke presented
Prof Chandra Kumar
the preliminary results of a one-year survey of adverse events associated with

Associate Editors cataract surgery. This showed a marked increase in the use of the sub-Tenons
Dr Monica Hardwick technique for local Anaesthesia since the last audit in 1996. Although the data
Dr Stephen Mather
for adverse events were incomplete it appears that “no needle” i.e. topical or
Mr David Smerdon
sub-Tenons anaesthesia is associated with a lower incidence of sight or life
Dr Sean Tighe
threatening complications.
The Society cannot be held
responsible for the statements or
There were a number of parallel workshops running during the remainder of
views of the contributors. No part
the Thursday morning including such topics as; Needle Block techniques, Sub-
of this Newsletter may be
reproduced without prior Tenon’s technique, Anatomy for eye blocks and Education and Ophthalmic
permission. Anaesthesia. With careful planning it was possible for delegates to attend all of
the workshops during the congress.
Articles of interest for future

issues or correspondence should
be sent by post, disk or email: After Lunch, came a session on Ophthalmic injury and Anaesthesia, which
started with Chris Dodds showing some rather graphic photographs of
Professor Chandra Kumar
Traumatic Eye injuries. Roy Hamilton described iatrogenic injuries mainly
Department of Anaesthesia
produced by sharp needle local anaesthetic techniques, but also reminded us
James Cook University Hospital
Middlesbrough TS4 3BW, UK that damage can be caused by over enthusiastic digital compression.
Tel [phone]
Fax [phone]
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[email protected]
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Ophthalmic Anaesthesia News, Issue 10, July 2004
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Steve Gayer from Miami described the
Anaesthetic management of patients presenting
with Ophthalmic Trauma, which can include
regional techniques as long as they avoid rises in
intra-ocular pressure when the globe has been
perforated. Dr Emile Callenda from Rouen,
France presented the management of pain after
ophthalmic injury including superficial injury
such as abrasion and more serious injury such as
ocular burns. He stressed that topical anaesthesia
should be reserved for examination or minor
surgery, and should not be used for treatment of
painful ocular conditions, because of adverse

effects on lacrimation and tear film stability.
Professor Roy Hamilton, President, International
Ophthalmic Anaesthesia Society

Professor Chandra Kumar, Organiser, World

Congress of Ophthalmic Anaesthesia
Mr Nick Astbury, President, The Royal College
of Ophthalmologists, London

Professor Chris Dodds, Chairman Scientific

Committee and BOAS President
Dr Doug Justins, Senior Vice President, The
Royal College of Anaesthetists, London

Ophthalmic Anaesthesia News, Issue 10, July 2004
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Dr Steve Gayer giving his presentation Mr Tim Dowd and Mr David Smerdon enjoying
drinks in the bar

Dr Anthony Rubin and Dr Ann Dodds enjoying
dinner at Dr Rubin’s house Mrs Elaine Tucker, Congress Administrator, Dr
Mani Mehta and guest enjoying dinner at the
Berkley Hotel

The last session of the afternoon was entitled
Perioperative Management of Ophthalmic
Patients and had a truly international flavour,
with speakers including Marc Feldman from
Ohio, Bob Johnson from Bristol and Helena
Kallio from Finland, who all gave excellent
presentations. However, the presentation which
produced the greatest response from the audience,
was given by Daniel Espada Lahoz from Sao
Paulo on the subject of sedation. This was twenty
minutes of hilarious animated visual cartoons

with sound effects, which reduced the whole
Dr Gary Fanning, Dr Mani Mehta, Mrs Arline audience to tears of laughter – it was the funniest
Fanning and Mrs Suchi Kumar enjoying dinner at presentation at a scientific meeting that I have
Dr Rubin’s house ever witnessed, and Dr Lahoz was given a huge
round of applause and several shouts of “encore”!

Ophthalmic Anaesthesia News, Issue 10, July 2004
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The Conference Dinner was held at the After lunch, the free papers were presented in
prestigious Berkley Hotel in Knightsbridge in two parallel sessions of four papers each, so it
truly palatial surroundings and was attended by was impossible to attend them all. Half of them
about ninety delegates, faculty and their partners. were on the subject of sub-Tenon’s, three on
The food was of exceptional quality, the service intravenous sedation and one on a local
was excellent, and many agreed that it was one of anaesthetic technique for trabeculectomy.
the best conference dinners they had attended. According to my colleagues, all the papers were
of high standard, but one particularly impressed
Friday morning dawned fine and sunny, and the me. This was a paper on orbital exenteration
first session sponsored by Abbott Laboratories under local anaesthesia with intravenous sedation,
Ltd was on the subject of Pharmacology and Eye presented by Anne Cook, an Oculoplastics
Anaesthesia. The five excellent speakers came Fellow from Manchester. The paper was so
from as far afield as India, The Netherlands and beautifully presented and the subject so
South Africa. Hamish McLure from Leeds, interesting that I almost forgot my duty as
persuaded us that the addition of adrenaline and timekeeper! In addition to the free papers there
hyalase to our local anaesthetic mixture was was also an excellent video being shown during
probably unnecessary, and Dr Uday Gorakhsa the lunch and coffee breaks, on peribulbar
from Mumbai suggested intravenous lidocaine technique, by Dr John Prosser from Worcester.
2% up to 2mg/kg as a useful technique for Several pharmaceutical and equipment
lowering intraocular pressure. companies, who financially supported the
congress, provided other entertainment during the
The four parallel workshops were repeated again breaks.
after the coffee break on the same topics, but with
different faculty, and then followed the Annual The final session of the Congress, on Innovations
General Meeting of the Society. Several in Ophthalmic Anaesthesia was again an
important announcements were made including international affair with speakers from Nimes,
the decision by Chandra Kumar to hand over the Cairo and Auckland who all gave excellent
post of Secretary to Sean Tighe from Chester. lectures. However, it was when The chairman Dr
The President thanked Chandra on behalf of Roy Hamilton introduced Chandra Kumar and
council for all his hard work and enthusiasm in congratulated him on his creation and success of
creating and maintaining the Society. Other the society, his unstinting work as secretary, and
announcements were that Ken Barber from the success of the World Congress, that an
Worcester would take over as President of the unusual event occurred – The audience gave
Society from April 2005, and the next Annual Chandra a standing ovation! I have rarely seen
Scientific meeting would take place in Jersey on such a demonstration of appreciation shown at a
June 9th and 10th 2005. A proposal was made for scientific meeting and it was certainly well
a four yearly World Congress of Ophthalmic deserved.
Anaesthesia and this was strongly supported by
the membership, with offers of hosts from Egypt So congratulations go to Professor Chandra
and South Africa. A new logo is being sought for Kumar and his excellent support team, for an
the Society’s letterheads, and the membership enormously successful World Congress of
were asked to submit their artistic ideas. Ophthalmic Anaesthesia. We all look forward to
the next!
Following the AGM there was a presentation of
two Lifetime Achievement awards in Ophthalmic
Anaesthesia, one to Dr Bob Johnson, the first Dr Monica Hardwick, BOAS Council Member,
President of BOAS and the other to Dr Gary Worcester, UK
Fanning the past president of the OAS. Both
recipients were complimented on their numerous
contributions to Ophthalmic Anaesthesia and
BOAS over the years.

Ophthalmic Anaesthesia News, Issue 10, July 2004
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Orbital exenteration under local anaesthesia spread on to the lower lid (photograph A).
with intravenous sedation Possibly it had become necrotic and
haemorrhaged.
A Cook, R M Slater, B Leatherbarrow,
Manchester Royal Eye Hospital The gentleman had previous ischaemic heart
Manchester, UIK disease and a degree of renal failure, hence the
Introduction decision to utilise local anaesthesia with sedation
Orbital exenteration was first described by for the exenteration.
Gaisford in 1963 (1). It is a disfiguring operation,
involving the removal of the entire contents of the The patient underwent a ‘tailored’ exenteration;
orbit, with or without the eyelids. It is most sparing the upper lid skin, but removing the entire
commonly performed for the management of lower lid. Intra-operatively, the blood pressure
malignancies such as choroidal/lid/conjunctival averaged 120/60, and the pulse 65 and regular.
melanoma (2,3), basal cell carcinoma (4),
sebaceous or squamous cell carcinomata (5,6), Post-operatively, the patient recovered well and
lacrimal gland tumours (7), and sino-nasal was discharged the following day. The socket
tumours with orbital spread (8). It is also used to healed well, with no infection.
manage benign conditions such as end-stage
socket contracture (9), and infections, such as Patient Number 2
mucormycosis (10). 64 year old male.
The patient was referred from a distant plastic
It is widely felt that such extensive surgery can surgery unit with orbital invasion of a lower lid
only be performed under general anaesthesia. basal cell carcinoma. He had undergone a local
Most patients requiring an exenteration are resection (non-Mohs’) and reconstruction ten
elderly, with significant co-morbidities, in whom years before. When he re-presented with lower lid
general anaesthesia poses significant risks. tethering, a CT scan revealed the extent of the
Sedation in the form of intra-venous midazolam invasion.
has previously been successfully used for the
management of intra-operative anxiolysis during He had considerable medical co-morbidity,
routine oculoplastic procedures performed on a including Hodgkin’s lymphoma, four myocardial
day-case basis (11). We therefore wished to infarction, hypertension, and chronic obstructive
enhance this technique for the more extensive airways disease.
procedure of orbital exenteration. We report our
experience with a group of patients who He underwent complete exenteration. Intra-
underwent orbital exenteration under local operative blood pressure readings were stable,
anaesthesia with intravenous sedation. averaging 130/80, with a regular pulse rate of 68.
Post-operatively he was moderately nauseated,
Patients and Methods but this settled with treatment and was discharged
Over a two-year period, five patients underwent home the following day. His socket healed well
total orbital exenteration under local anaesthesia and he was able to be fitted with a prosthesis.
with intravenous sedation:
Patient Number 3
Patient Number 1 70 year old female.
91 year old male. The patient had undergone enucleation for ocular
The patient was referred from a peripheral unit trauma many years previously. Despite several
with a sudden increase in size of a pigmented procedures to aid fitting of her artificial eye, she
right caruncular lesion. This had been watched had ended up with end-stage contracture of the
over the last 10 years, during which time it had socket and was referred for exenteration.
remained static. She was wheel chair bound, with a past medical
Upon examination, the lesion appeared to have history including 3 cerebrovascular accident,
extended along the inferior conjunctiva and had thyroid dysfunction, and hypertension.

Ophthalmic Anaesthesia News, Issue 10, July 2004
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7
disease.
She underwent a lid-sparing exenteration, and
intra-operatively the blood pressure averaged A complete exenteration was carried out with
160/90, and the pulse 78. stable blood pressure and pulse throughout. The
patient was discharged to a nursing home the
Post-operatively she recovered quickly and following day.
returned home the following day.
Technique
All patients had venous cannulation and received
Patient Number 4 midazolam 1-2mg as a bolus followed by a
68 year old male. target-controlled infusion (TCI) of propofol in the
The patient had a long history since his first range 0.2-2 microgram/ml. Patients were
herpetic corneal ulcer eventually resulted in him monitored with pulse oximetry, ECG, non-
undergoing a penetrating keratoplasty. This invasive blood pressure and respiration before
failed, as did a second, and the eye was sedation, and throughout surgery they received
enucleated ten years later. He had a Roper-Hall supplemental oxygen.
orbital implant inserted, but this extruded five
years later. The socket then became grossly Local anaesthesia was provided with a 10ml peri-
contracted and he was unable to wear an artificial bulbar injection of bupivicaine 0.5% with
eye. adrenaline 1:200,000 with 5000 units of
hyaluronidase, (figure 1).
He had severe Rheumatoid arthritis, with plates in
his cervical vertebrae, as well as Raynaud’s Thereafter, a further 10ml injection of bipivicaine
disease. 0.5% with adrenaline 1: 200,000 was infiltrated
locally around the orbital rims to directly block
He underwent a lid-sparing exenteration, with the supra-trochlear, supra-orbital, infra-trochlear,
stable blood pressure and pulse intra-operatively, infra-orbital, anterior ethmoidal, zygomatico-
averaging 120/60 and 80 respectively. facial and zygomatico-temporal nerves, (figure
2).
He had no post-operative complications, and was
discharged the following day. Patients were monitored at all times during
The socket has healed well, and a prosthesis has surgery by the anaesthetist (RMS) who altered
been fitted. the TCI of propofol according to the surgical
stimulus. The patient was specifically monitored
Patient Number 5 for signs of an oculo-cardiac reflex.
88 year old female.
This lady had undergone the first excision of her A standard exenteration was then performed, with
right lower lid basal cell carcinoma 12 years age or without the lids, according to the pathology
under the care of a local plastic surgery unit. The involved.
lid had been reconstructed utilising a local
myocutaneous flap but unfortunately the lesion Results
recurred. Over the following ten years she All patients tolerated the procedure well, with no
underwent four procedures to attempt clearance episodes of hypoxaemia or bradycardia. A
and reconstruction, as well as one course of respiratory rate of > 8/minute was maintained at
radiotherapy. Eventually, she was referred with all times. No patients experienced pain
the lower lid contracted and tethered to the intraoperatively. No patient required any
inferior orbital rim, such that it was impossible to additional postoperative analgesia, other than
see the globe. routine non-steroidal agents. All patients were
discharged home on the first post-operative day.
The patient was frail with a degree of congestive
cardiac failure, hypertension, and ischaemic heart

Ophthalmic Anaesthesia News, Issue 10, July 2004
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Carcinoma of the Eyelids’. Ophthal Plast
Reconstr Surg. 1998 May; 14 (3): 216-21.
5. Snow SN, et al. ‘Sebaceous Carcinoma of the
Eyelids Treated by Mohs’ Micrographic
Surgery’. Dermatol Surg. 2001 Jul; 28 (7):
623-31.
6. McElvie PA, et al. ‘Squamous Cell
Carcinoma of the Conjunctiva’. Br J
Ophthalmol. 2002 Feb; 86 (2): 168-73.
7. Becelli R, et al. ‘Pleomorphic Adenoma of
the Lacrimal Gland’. J Craniofac Surg. 2002
Jan; 13(1): 49-52.

Fig 1. 8. Bridger, et al. ‘Craniofacial Resection for
Paranasal Sinus Cancers’. Head Neck. 2002
Dec; 22(8): 772-80.
9. Dolphin KW. ‘Complications of Post-
enucleation / Evisceration Implants’. Curr
Opin Ophthalmol. 1998 Oct; 9(5): 75-7
10. Nithyanandam S, et al. ‘Rhino-orbito-cerbral
Mucomycosis’. Indian J Ophthalmol. 2003
Sep; 51(3): 231-6.
11. Biswas S, Leatherbarrow B, et al. ‘Low Dose
Midazolam Infusion for Oculoplastic Surgery
under Local Anaesthesia’. Eye. 1999 Aug;
13(4): 537-40.

Fig 2.

Conclusion

We have demonstrated that such extensive orbital

surgery can be carried out safely and

satisfactorily in a population of frail elderly

patients, without the potential risks of general
anaesthesia.

References
1. Gainsford JC, Hanna DC. ‘Orbital
Exenteration’. Plast Recon Surg. 1963, April;
31: 363-9.
2. Murthy GG, Ingole AB, Desai S. ‘Malignant
Melanoma in eviscerated Eyeball’. Clin
Experiment Ophthalmol. 2004 Feb; 32 (1):
103-5.
3. Mittica N, et al. ‘Late Recurrence of a
Choroidal Melanoma following Internal
Resection’. Survey Ophthalmol. 2003 Mar-
Apr; 48(2): 181-90.
4. Bonner PK, et al. ‘Mixed Type Basal Cell

Ophthalmic Anaesthesia News, Issue 10, July 2004
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Life Time Achievements a private outpatient facility in Sycamore, a
satellite community of Chicago, Illinois. He
Awards
remains in that position to the present time. I am
pleased to acknowledge that Lynne Hauser and

Neil Ross are here in our audience today, joining
Dr Gary Fanning, Sycamore, USA
the rest of us in honouring their loyal colleague.

Citation read by Professor R. C. Hamilton,
Starting 20 years ago was the first of the
Calgary, Canada
ophthalmic anaesthesia societies, known simply

as the Ophthalmic Anaesthesia Society, under the
leadership of Dr. Robert F. Hustead, Bob Hustead
for short. Bob had a dream of promoting the
subspecialty of anaesthesia for all manner of eye
surgery; he was indeed the founding father of the
OAS. Like many of us, Gary benefited from
regular attendance at the annual scientific
meetings of OAS and soon was to become its
program director, a position he held for seven
years. Currently Gary is editor of a lively OAS
newsletter aptly named OASIS. The memberships
of OAS now numbering more than 150 eagerly
await each issue of this beautifully produced
publication. And as if this were not enough, Dr.
Fanning has jointly edited a recently published
textbook on ophthalmic anaesthesia, in addition
to which he has published many peer-reviewed
articles.

Behind every successful man there is a
powerhouse of support; this can most certainly be
said of Gary’s helpmate, Arline. There must be a

gene for jurisprudence in their family; two sons

and a daughter are all lawyers!
It is a great pleasure and honour to present to you

Dr. Gary Fanning, for inauguration as a Lifetime
Ladies and gentlemen, it is with great pleasure
Member of the British Ophthalmic Anaesthesia
that I ask Dr. Gary Fanning to come forward to
Society.
accept this certificate signifying lifetime

membership of the British Ophthalmic
Dr. Fanning obtained his MD from the University
Anaesthesia Society.
of Syracuse in 1966. His residency in anaesthesia

was at the University of Rochester, New York,

following which he completed his military
Dear BOAS members:
service.
I wish to thank you all for the honour you

bestowed on me by giving me the Lifetime
There followed a staff anaesthesiologist
Achievement Award at your annual meeting in
appointment at the renowned McFarland Clinic in
London in April. As I mentioned in my remarks
Ames, Iowa where he served for nineteen years
at the time, never has an award been less
and was responsible for anaesthesia for a wide
deserved nor more gratefully received.
range of surgical specialties.

My association with the British Ophthalmic
In 1991 Gary took up the position as senior
Anaesthesia Society has been one of the most
anesthesiologist at the Hauser-Ross Eye Institute,

Ophthalmic Anaesthesia News, Issue 10, July 2004
Email: [email protected] Website http://www.boas.org
10
happy and productive of my career. I have been
welcomed by you; blessed with your warmth and It is a particular pleasure to say a few words
hospitality; impressed and enlightened by your about Bob Johnson, who has so many different
knowledge and experience; and awed by your attributes.
abilities to organise and communicate. I know
that I have received more than I have imparted. Although we are here primarily to mark his
contributions to ophthalmic anaesthesia, it should
I also wish to thank all of you who worked so not be forgotten that he was a renowned obstetric
hard to achieve the tremendous success of the anaesthetist who filled the post of honorary
first World Congress of Ophthalmic Anaesthesia. secretary of the Obstetric Anaesthetists
It was a marvellous meeting, and your Society Association. He is also very well known in the
deserves the highest degree of congratulations for field of chronic pain, being one of the leading
having organised and carried out such an event. lights in the management of herpes zoster and
It was truly an honour to have been a delegate at especially post-herpetic neuralgia. He is
this inaugural conference. regularly invited to lecture and to take part in
working groups on this very difficult subject.
I send my warmest regards to you all along with
my deepest gratitude for all the kindness you As an ophthalmic anaesthetist he has been a
have given me. regular attendee at the British Ophthalmic
Anaesthesia Society and was its first President.
Sincerely, His devotion to that task set the Society on the
right road and under his leadership it grew to its
Gary L. Fanning, MD present healthy and established position. He has
Sycamore, Illinois, USA published with Frances Forrest an excellent
textbook on ophthalmic anaesthesia.
Dr Robert Johnson, Bristol, UK
He is a renowned lecturer, and always in demand
Citation read by Dr Anthony Rubin, London, for meetings large and small. His excellent
UK command of the English language, coupled with
an almost faultless, and never excessive, use of
audiovisual aids, make him the perfect model for
others to follow.

Recently he was away at an international
conference, and he knew that on his return he
would need a human skull to aid him in imminent
workshops on ophthalmic regional anaesthesia.
To be sure not to forget it, he left it on his
entrance hall table, and set his burglar alarm to
safeguard his lovely house. Unfortunately during
his temporary absence the alarm went off and, as
it was linked to the police station, the police duly
arrived with the nominated key holder. They
were more than surprised to be greeted by the
human skull. We do not know yet whether they
are digging up his garden to find the rest of the
body!

Behind all eminent men, there is an exceptional
woman, and Bob has been ably supported and

Ophthalmic Anaesthesia News, Issue 10, July 2004
Email: [email protected] Website http://www.boas.org